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Rule of thumb in General surgery
Background
General surgery in sub-Saharan Africa presents unique challenges due to limited resources, variable access to specialized care and a high burden of surgical diseases including trauma, infections and malignancies. The following rules of thumb and guidelines can help improve surgical outcomes and patient safety in this region.
- Thorough Assessment: Begin with a detailed history and physical examination to accurately diagnose and plan the appropriate surgical intervention. This is crucial in settings where advanced diagnostic tools may be limited.
- Prioritize Emergencies: Focus on life-threatening conditions such as trauma, acute abdomen, and obstructed hernias. Prompt intervention can significantly reduce morbidity and mortality.
- Sterility and Infection Control: Maintain strict aseptic techniques to prevent infections. This includes proper sterilization of instruments, using sterile gloves, and maintaining a clean surgical environment.
- Resource Optimization: Make efficient use of available resources. This may involve reusing equipment where safe, utilizing locally available materials, and adapting surgical techniques to fit the context.
- Basic Surgical Skills: Ensure all healthcare providers are proficient in basic surgical skills and common procedures, including suturing, incision and drainage, and basic trauma management.
- Task-Shifting and Training: Train non-specialist healthcare workers to perform essential surgical tasks and recognize complications, thereby extending the reach of surgical care in rural and underserved areas.
- Preoperative and Postoperative Care: Focus on thorough preoperative preparation and meticulous postoperative care. This includes proper patient assessment, managing comorbidities, and ensuring effective pain management and wound care.
- Patient Education and Consent: Educate patients and their families about the surgical procedure, expected outcomes, and potential risks. Obtain informed consent by explaining the procedure in understandable terms.
- Multidisciplinary Approach: Collaborate with other healthcare professionals, including anaesthetists, nurses, and community health workers, to provide comprehensive care and improve surgical outcomes.
- Follow-Up and Rehabilitation: Ensure adequate follow-up to monitor for complications, promote recovery, and provide necessary rehabilitation. This may involve community health workers conducting home visits and follow-up calls.
- Cultural Sensitivity: Respect and incorporate local cultural practices and beliefs into surgical care, which can improve patient compliance and satisfaction.
- Evidence-Based Practices: Where possible, apply evidence-based guidelines tailored to local resources and contexts. Continuously update knowledge and skills to incorporate best practices.
Rules of thumb
1. Preoperative Assessment and Preparation
Effective preoperative assessment is crucial in regions with limited diagnostic facilities, ensuring that only patients who are fit for surgery proceed to the operating room.
Rules of Thumb
Thorough Clinical History and Physical Examination:
Given limited diagnostic resources, a thorough clinical history and detailed physical examination are essential for diagnosis, assess patient’s fitness for surgery. Identify comorbid conditions such as hypertension, diabetes and malnutrition.
Basic Laboratory Tests:
Perform basic blood tests (haemoglobin, blood glucose, renal function) and urine test such as urinalysis to assess surgical risk, especially in anaemic or malnourished patients. Blood typing and cross matching are necessary if there is a risk of significant blood loss.
Preoperative Optimization:
optimising the patient preoperatively by correcting anaemia, dehydration or electrolyte imbalances help to prevent perioperative complications. treatment of any active infections with antibiotics and provision of nutritional support for malnourished patients are all important for successful outcome. Counselling the patient and obtaining an informed consent is essential.
Guidelines
WHO Guidelines on Safe Surgery: Recommend the use of preoperative checklists to ensure adequate patient preparation, including basic blood work, nutritional status assessment, and infection control. These guidelines also emphasize infection prevention measures such as antibiotics and tetanus prophylaxis.
2. Infection Prevention and Control
Infection is a major contributor to morbidity and mortality in general surgery especially in resource-constrained settings with poor sanitation.
Rules of Thumb
Use Prophylactic Antibiotics:
Administer prophylactic antibiotics before surgery, particularly in high-risk procedures (e.g., bowel surgery, trauma cases). Start antibiotics within 60 minutes of incision and discontinue them within 24 hours postoperatively.
Aseptic technique:
all surgical procedures should be done under aseptic technique , including proper handwashing, use of sterile gloves, gowns, face mask and appropriate skin antisepsis and draping of operation field. Ensure that sterile instruments are available, especially in rural settings where sterilization equipment may be lacking.
Guidelines
WHO Surgical Site Infection Guidelines: Emphasize the use of sterile barriers, hand hygiene, and timely administration of antibiotics to prevent surgical site infections. These guidelines recommend avoiding prolonged antibiotic use post-surgery to reduce antimicrobial resistance.
3. Trauma Care
Trauma is a leading cause of surgical admissions in sub-Saharan Africa, often resulting from road traffic accidents, violence and occupational injuries.
Rules of Thumb
ABCDE of Trauma Management:
Follow the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to trauma care. Ensure that the airway is clear, provide oxygen if needed, and stop any external bleeding. Stabilize fractures and spinal injuries.
Prioritize Life-Threatening Injuries:
In resource-limited settings, focus on addressing immediate life-threatening conditions such as internal bleeding, traumatic brain injury, and penetrating trauma before dealing with fractures or soft tissue injuries.
Early Transport for Surgical Intervention:
If trauma exceeds the local facility’s capacity, stabilize the patient and arrange rapid transport to a higher-level hospital. Rural and smaller hospitals should have protocols for transferring trauma patients to appropriate care centres.
Guidelines
Advanced Trauma Life Support (ATLS) Guidelines: Recommend the systematic approach to trauma care through primary and secondary surveys to address immediate life threats. WHO trauma guidelines for low-resource settings emphasize the importance of triaging patients and providing basic life-saving interventions while awaiting transport.
4. Management of Acute Abdomen
Acute abdominal emergencies are common in sub-Saharan Africa, often presenting with complications due to delayed access to care.
Rules of Thumb
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Urgent Evaluation:
Any patient presenting with features of acute abdomen (severe abdominal pain, guarding, or rigidity) should be evaluated urgently. Initial resuscitation with oxygen supplementation, fluids, nasogastric tube insertion, urethral catheterisation, antibiotics and analgesics should be done. .a detail history, exam and appropriate investigation to make a diagnosis of causes of surgical abdomen should be expedited. A delay in surgical intervention should be avoided even if radiological investigation is unavailable in which case diagnosis should be based on clinical assessment only.
Guidelines
WHO Emergency Surgery Guidelines: Recommend rapid clinical assessment of patients with acute abdomen to determine the need for surgery. Guidelines emphasize that time-sensitive interventions can save lives and that decision-making should not be delayed for extensive diagnostics in resource-poor environments.
5. Postoperative Care and Follow-Up
Postoperative care is often compromised by limited resources, poor patient follow-up, and lack of rehabilitation services.
Rules of Thumb
Postop Management:
Adequate fluid administration, antibiotics (when indicated), analgesics and provision of calories is important for patient survival. Close monitoring of vital signs including pulse, BP, RR and temp. early mobilisation and prevention of DVT is important. Anticipation, early detection prompt intervention of postop complications improves patient outcome.
Pain Management:
Provide effective pain management, even in resource-limited settings. Use basic analgesics such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), and consider opioids for severe pain.
Wound Care:
Ensure that wounds are monitored closely for signs of infection. Provide proper dressing changes, and educate patients on hygiene and wound care practices to prevent infections.
Guidelines
WHO Guidelines on Postoperative Care: Stress the importance of monitoring for postoperative complications, early ambulation, and pain management. These guidelines emphasize that appropriate wound care and infection control are critical in reducing postoperative morbidity.
6. Surgical Oncology
In sub-Saharan Africa, cancer surgery is often complicated by late presentation, limited diagnostic facilities, and inadequate access to radiotherapy and chemotherapy.
Rules of Thumb
Early Detection and Referral:
A public awareness about the early symptoms of cancer particularly breast, cervical, and gastrointestinal cancers and the importance of seeking prompt medical attention can help to improve survival.
A surgery for Curable Cancers:
The treatment of cancer is multimodal involving surgery, chemotherapy, radiotherapy, hormonal therapy and targeted therapy. surgery should only be undertaken if the tumour is resectable and the benefit outweighs the risk. The unavailability of all or part of the modality of treatment should warrant early referral to a higher well equipped centre. For resectable tumours, aim for complete tumour excision with clear margins.
Palliative Surgery:
For patients with advanced-stage cancer, offer palliative surgical interventions to relieve symptoms and improve quality of life with opioid analgesia, chemotherapy, and psychotherapy.
Guidelines
WHO Guidelines for Cancer Management in Low-Resource Settings: Focus on early detection, timely referral, and surgical management where possible. For advanced cancers, these guidelines stress the importance of palliative care and symptom management.
7. Rural and Resource-Limited Surgery
Many surgeries in sub-Saharan Africa are performed in rural or resource-limited settings where surgical infrastructure may be lacking.
Rules of Thumb
Basic Surgical Techniques:
In rural areas where surgical instruments and facilities are limited, surgeons should be skilled in basic procedures such as hernia repairs, appendectomies, and amputations. Surgical improvisation and creativity may be required to deal with resource constraints.
Task Shifting:
In areas with few surgeons, task shifting to trained medical officers or non-physician clinicians can help address the surgical burden. Ensure proper training and supervision in performing basic emergency surgeries.
Referral Networks:
Establish a robust referral system for patients who require specialized surgical care. Communication between rural clinics and larger hospitals is key to ensuring timely transfers for more complex procedures.
Guidelines
WHO Global Surgery Guidelines: Support the development of rural surgical systems, task shifting to trained non-surgeons, and the creation of referral networks to improve access to surgical care. These guidelines emphasize building capacity for essential surgeries in rural and underserved areas.
8. Anaesthesia in Resource-Limited Settings
Safe anaesthesia is often a challenge in sub-Saharan Africa due to the scarcity of anaesthesiologists, limited access to modern equipment, and unreliable electricity.
Rules of Thumb
Simple Anaesthetic Techniques:
Where advanced anaesthesia equipment is unavailable, use simple and effective techniques like ketamine anaesthesia or spinal anaesthesia for certain procedures. These can be safely administered by trained non-physician anaesthetists.
Preoperative Anaesthetic Risk Assessment:
Assess patients for risks such as difficult airways, cardiovascular instability, or respiratory issues. In resource-limited settings, err on the side of caution, particularly in patients with multiple comorbidities.
Monitoring During Surgery:
Even with limited equipment, ensure that vital signs such as pulse, blood pressure, and oxygen saturation are monitored throughout the procedure.
Guidelines
WHO Anaesthesia Guidelines: Recommend using simple and safe anaesthesia techniques, particularly in resource-constrained settings. They emphasize the importance of training and equipping non-physician anaesthetists and the use of monitoring protocols, even in low-resource environments.
Conclusion
Surgical interventions should be combined with public health efforts, such as trauma prevention, cancer screening, and infection control, to reduce the overall surgical burden in sub-Saharan Africa. Building capacity for essential surgeries in rural and underserved areas, enhancing the training of healthcare providers, and improving referral networks are critical steps toward providing accessible and safe surgical care. The integration of WHO and other global surgical guidelines tailored to resource-limited settings can help reduce mortality and morbidity. Finally, investments in infrastructure, equipment, and human resources for health are crucial to ensuring sustainable improvements in surgical care across the region. By adhering to these rules of thumb and guidelines, healthcare systems can achieve better outcomes and increase the reach of lifesaving surgery for the population.
Further readings
- WHO Safe surgery. https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery%203%20April%202009 Accessed 12th September 2024.
- Global guidelines for the prevention of surgical site infection1 December 2018. https://www.who.int/publications/i/item/9789241550475 Accessed 12th September 2024.
- Paydar S, Farhadi P, Ghaffarpasand F. Advanced Trauma Life Support (ATLS) Tips to Be Kept In Mind. Bull Emerg Trauma. 2013 Jan;1(1):49-51. PMID: 27162823; PMCID: PMC4771244. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4771244/ Accessed 12th September 2024.
- Best practice guidelines on emergency surgical care in disaster situations 29 January 2007 https://www.who.int/publications/i/item/best-practice-guidelines-on-emergency-surgical-care-in-disaster-situations Accessed 12th September 2024.
- National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; National Cancer Policy Forum. Cancer Care in Low-Resource Areas: Cancer Treatment, Palliative Care, and Survivorship Care: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2017 Nov 14. Proceedings of a Workshop. Available from: https://www.ncbi.nlm.nih.gov/books/NBK533384/
- WHO Postoperative Care. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/surgical-care/imeesc-toolkit/best-practice-safety-protocols/post-operative-care.pdf?sfvrsn=814e0c4f_5 Accessed 12th September 2024.
- Surgical and Anaesthesia Care. https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/surgical-care. Accessed 12th September 2024.
- WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) https://www.who.int/initiatives/who-global-initiative-for-emergency-and-essential-surgical-care Accessed 12th September 2024.
